USAFP: AHLTA Master Coder Template

1. USAFP: AHLTA Master Coder Template MAJ Jeremy Johnson Faculty Development Fellow

2. Goals • Import the master coder template • Demonstrate the S/O portion of the master coder template • Demonstrate the A/P portion • Modify the template • Create an order set and add it to the master coder template

3. Import the master coder template

4. First Place your USAFP coding CD into the CD drive on your computer

5. Double click on your patient to open the encounter.

6. Click the Templates Button at the top of the opening screen.

7. You will now come to this screen.

8. Click the Import button to import the master coder template.

9. Click this pull down arrow.

10. Choose your CD drive from the list. It may have a CD icon next to the drive letter.

11. Double click over the USAFP coding folder.

12. You will see the master coder template appear here. Ensure you see the word Personal (with your name in parentheses) at the bottom of the screen.

13. Now, with the master coder template highlighted, click the Arrow pointing to the right. …

14. You will now see the master coder template over to the right of the screen. Ensure Add to Favorites is checked and click Import.

15. You will then come to this screen to show that the encounter template is loaded with you as the owner and you will see Yes under the Favorite column which means it is in your favorite list.

16. Now click Close and you will return to your patient encounter.

17. You have returned to your patient encounter

18. Review S/O portion of the master coder templateThis is still in progress…final version to be released at USAFP conference

19. Open your patient encounter and click on S/O.

20. Click the …. Down Arrow next to the words <No Template Selected>

21. Use the Scroll bar to go down until you find enc--master coder--usafp and click on it with your mouse.

22. This is still in progress… final version to be released at USAFP conference.

23. Review A/P portion of the master coder template

24. Go to the A/P section of your note.

25. Under the diagnosis tab you will see several common diagnoses listed.

26. You can scroll down for more diagnoses.

27. There are no orders under the Order Sets tab. We will add orders later.

28. The most commonly used Procedures are listed under the Procedures tab.

29. The Other Therapies tab lists counseling and anticipatory guidance.

30. Modify Diagnoses,Procedures, and Other Therapies on the master coder template

31. Get back to the opening screen for your patient and click Templates. ….

32. Here click on the + sign next to My Favorites.

33. Scroll down under your favorites and select your enc-- master coder--usafp template and then click View/Edit.

34. These are the buttons you have to work with within your encounter template. Add will add a diagnosis, Remove will remove the selected diagnosis, the arrows will move your diagnosis up or down on the priority list.

35. I have selected the Diagnosis V45.89 because I do not see post op patients much. I then click Remove.

36. The diagnosis V45.89 is now gone.

37. Now you can add some diagnoses that you use often but are not on this template.

38. You will come to this screen. Type in the code or the term you are searching for. Then click Search.

39. Select the appropriate diagnosis and then click Add Items.

40. If you want to add others, type in the term, click search, click on the term you want, and click Add Items. Click Done if you have no more terms to add.

41. Now scroll down until you find the diagnoses you just added.

42. Click on the diagnosis you want to move then click the up arrow multiple times until the diagnosis is where you want it to be.

43. I have moved it into the #3 position since I will use both V72.31 and V76.2 on almost every well woman exam.

44. I have also moved up V76.47 as this code should be used when a PAP is done on women without a cervix.

45. I can use the same buttons for the Procedures Section with one limitation.

46. One cannot add HCPCS terms (i.e. procedures that start with a letter). This is done with a very complex method and thus the key HCPCS terms are already in this template for you.

47. You can add CPT codes. Type in the code, click Search, select the CPT code you want, Click Add Items, then click Done.

48. The procedure now appears under your list.

49. You can use the same technique with Other Therapies.

50. You can add therapies. Type in the therapy, click Search, select the therapy you want, Click Add Items, then click Done.